Fill and Sign the Application for Hearing Medical Care Provider 024utah Form

Form 024 6/18/14 State of Utah - Labor Commission Division of Adjudication 160 East 300 South, 3 rd Floor, P.O. Box 146615 Salt Lake City, Utah 84114-6615 (801) 530-6800 casefiling@utah.gov Note: PLEASE TYPE OR PRINT IN BLACK INK ____________________________________________ Medical Care Provider (Petitioner) ____________________________________________ Injured Employee vs. ____________________________________________ Respondent (employer) ____________________________________________ Respondent’s mailing address ____________________________________________ City, State and Zip Code ____________________________________________ Respondent’s phone number ____________________________________________ Respondent’s worker’s comp insurance carrier * ____________________________________________ Insurance Carrier’s mailing address ____________________________________________ City, State and Zip Code ____________________________________________ Insurance Carrier’s phone number APPLICATION FOR HEARING MEDICAL CARE PROVIDER (NOTE: Include all supporting documentation when this form is filed with the Labor Commission or the Application for Hearing may be returned) I request to have a Claims Resolution Conference scheduled to resolve the issues checked below YES NO *It is the petitioner’s obligation to provide the mailing address and phone number for respondent’s insurance carrier. If you do not have this information you may obtain this information on the Labor Commission website, Industrial Accidents Division Workers’ Compcheck or contact the employer or the Industrial Accidents Division. PETITIONER ALLEGES AND REQUESTS RESOLUTI ON CONCERNING THE FOLLOWING UNDER TITLE 34A: 1. Date of industrial injury: Month_____Date___Year_____. 2. Medical Charges at issue (you must attach an itemized, de tailed account of the services rendered, the date of the services, the charges for the services, and the correct RVRBS billing code): 3. Amounts paid by res pondents to date:_______________________________________________________\ . Form 024 6/18/14 4. The injuries employee sustai ned from the accident are:_________________________________________________ ________________________________________________________________________\ ____________________ 5. If you are billing for restorative services you must include RSA forms. Petitioner verifies that the above information is true a nd correct to the best of petitioner’s information and belief. ____________________________________________ Printed Name of Attorney for Petitioner State Bar # ____________________________________________ Signature of Attorney for Petitioner ____________________________________________ Mailing Address for Attorney for Petitioner ____________________________________________ City/State/Zip Code (___)_______________________________________ Telephone Number (___)_______________________________________ FAX E Mail Address ____________________________________________ Signature of Petitioner Date ____________________________________________ Mailing Address of Petitioner ____________________________________________ City/State/Zip Code (______)____________________________________ Petitioner’s Telephone Number ____________________________________________ Petitioner’s Social Security Number ____________________________________________ Petitioner’s E Mail Address If you know the name and address of the adjuster or third party administrator that you have dealt with concerning your claim please include that information: ___________________________________________________ Name of adjuster or third party administrator ___________________________________________________ Mailing Address for adjuster or third party administrator ___________________________________________________ City/State/Zip Code